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i <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # / INVOICE # <br /> FACILITY NAME �—�j i U\ �=, BILLING PARTY / <br /> SITE ADDRESS t C_- 141(`6 <br /> CITY ZP0 CA Z1P <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR 1�L'�V1t� �(J P 6BILLING PARTY ® / N <br /> DBA — PHONE #1 (.g <br /> MAILING ADDRESS O ' x l ? FAX # Z0 9)S <br /> CITY STATE "T ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> HS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> age 1 of this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> , JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT`S SIGNATURE ' <br /> Title:— �!:� Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: tis � Service Code 199-1 <br /> Assigned to ]�:'>-. Ix, C� c� Employee # J`1 7 j Date / JU ./ '1 7 <br /> Date Service Completed -/-/ Further Action Required: Y / N PROGRAM ELEMENT 2 WE <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> °2,3+. �a3� — "1110 /97 ✓ � �9a9sz (A <br /> SUPV / / ACCT / UNIT CLK _/ / <br />